Peripheral Artery Disease Lower Extremity
Overview
Overview
Top 10 Take-Home Messages
- Peripheral artery disease (PAD) is a common cardiovascular disease associated with increased risk of amputation, myocardial infarction, stroke, and death, as well as impaired quality of life, walking performance, and functional status.
- This guideline defines 4 clinical subsets of PAD: asymptomatic PAD (may have functional impairment), chronic symptomatic PAD (including claudication), chronic limb-threatening ischemia, and acute limb ischemia.
- Detection of PAD in most patients is accomplished through the history, physical examination, and the resting ankle-brachial index.
- Health disparities in PAD are associated with poor limb and cardiovascular outcomes and must be addressed at the individual patient and population levels, with interventions coordinated between multiple stakeholders across the cardiovascular community and public health infrastructure.
- Effective medical therapies for patients with PAD should be prescribed to prevent major adverse cardiovascular events and major adverse limb events for patients with PAD, including antiplatelet (generally single antiplatelet) and antithrombotic therapy, lipid-lowering (ie, high-intensity statin) and antihypertensive therapy, management of diabetes, and smoking cessation. Rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) is effective to prevent major adverse cardiovascular events and major adverse limb events in patients with PAD who are not at increased risk of bleeding.
- Structured exercise is a core component of care for patients with PAD. It includes supervised exercise therapy and community-based (including structured home-based) programs.
- Revascularization (endovascular, surgical, or hybrid) should be used to prevent limb loss in those with chronic limb-threatening ischemia and can be used to improve quality of life and functional status in patients with claudication not responsive to medical therapy and structured exercise.
- Care for patients with PAD, and especially those with chronic limb-threatening ischemia, is optimized when delivered by a multispecialty care team.
- Foot care is crucial for patients with PAD across all clinical subsets and ranges from preventive care and patient education to advanced care in the setting of chronic limb-threatening ischemia. Podiatrists and other specialists with expertise in foot care, wound-healing therapies, and foot surgery are important members of the multispecialty care team.
- The PAD National Action Plan outlines 6 strategic goals to improve awareness, detection, and treatment of PAD nationwide. Implementation of this action plan is recognized as a top advocacy priority by the writing committee.
In the print version of this pocket guide, colors in tables and figures correspond to Class of Recommendations and Level of Evidence tables on pages 54–55.
Table 2. Definitions of PAD Key Terms
| Term | Definition |
|---|---|
| ALI | Acute (≤2 wk) hypoperfusion of the limb that may be characterized by: pain, pallor, pulselessness, poikilothermia, paresthesias, and/or paralysis. ALI is further classified according to the Rutherford classification system (Table 4). |
| Anatomic level | Anatomic subsets to localize disease in the lower extremity. Patients with PAD can have multilevel arterial disease across multiple segments.
|
| Angiosome-based blood flow | Uninterrupted arterial flow to the anatomic territory of a source artery in the skin and deep tissues. In the context of PAD, the angiosome refers to the skin region and underlying tissue, generally with a wound, supplied by a specific infrapopliteal artery. |
| Claudication | Fatigue, cramping, aching, pain, or other discomfort of vascular origin in the muscles of the lower extremities that is consistently induced by walking and consistently relieved by rest (usually within approximately 10 min). Claudication that limits functional status is known as functionally limiting claudication. Claudication is recognized as a manifestation of chronic symptomatic PAD (see Section 2.1, “Recognizing Clinical Subsets for PAD”). |
| CLTI | A condition characterized by chronic (>2 wk) ischemic rest pain, nonhealing wounds and ulcers, or gangrene attributable to objectively proven arterial occlusive disease. Current nomenclature has evolved from the previous commonly used term of CLI to reflect the chronic nature of this condition and its potentially limb-threatening nature with associated risk for amputation and to distinguish it from ALI. |
| Endovascular revascularization | Catheter-based revascularization procedures employing modalities such as percutaneous transluminal (balloon) angioplasty, drug-coated balloon angioplasty, stenting (bare metal, drug coated, or covered), and atherectomy. |
| Functional status | Patient’s ability to meet basic needs, fulfill usual roles, and maintain health and well-being (activities of daily living). Walking ability/ performance and mobility are components of functional status. |
| Hybrid revascularization | Approach to revascularization that includes endovascular and surgical components either concomitantly or in a staged manner. |
| In-line (pulsatile) blood flow | Uninterrupted arterial flow via named infrapopliteal arteries to the foot. |
| Inflow versus outflow | Inflow refers to arteries proximal to the superficial femoral artery (aortoiliac, common femoral arteries). Outflow refers to arteries distal to the superficial femoral artery (popliteal and infrapopliteal arteries). |
| MACE | Variably defined but usually includes death (all-cause or cardiovascular), MI, acute coronary syndrome (acute MI, unstable angina), and stroke. May also include heart failure, rehospitalization for cardiovascular causes, and other cardiovascular endpoints. |
| MALE | Variably defined but usually includes major amputation and endovascular or surgical lower extremity revascularization (initial or reintervention). May also include ALI. |
| Multispecialty care team for PAD |
|
| Regions of the foot |
|
| Structured exercise program | An exercise program planned by a qualified health care professional that provides recommendations for exercise training with a goal of improving functional status over time. The program provides individualized recommendations for frequency, intensity, time, and type of exercise. |
| Structured community-based exercise program | A structured exercise program that takes place in the personal setting of the patient (eg, home, surrounding neighborhood, fitness facility). The program is self-directed with as-needed guidance of health care professionals who prescribe a structured exercise regimen similar to that performed in a supervised program setting. Community-based programs may incorporate behavioral change techniques, delivered by in-person or virtual health coaching or the use of activity monitors. Table 14 provides more detail regarding this form of structured exercise. |
| Supervised exercise therapy | A supervised, structured exercise program that takes place in a hospital or outpatient facility that is directly supervised by a physician or advanced practice provider and most often implemented by a clinical exercise physiologist or nurse. Table 14 includes more detail regarding this form of structured exercise. |
| Surgical revascularization | Surgical procedures that may involve endarterectomy to remove plaque, thrombectomy, or bypass surgery to reconstruct arterial blood flow. |
| Thrombolysis | Administration of thrombolytic agents, generally through a catheter placed directly within an area of thrombus in an artery. |
| Tissue loss |
|
| WIfI |
|
Diagnosis
...gnosis...
...Recognizing Clinical Subsets of PAD...
...linical Subsets of PAD...
...able 4. Clinical Subsets of Patients With...
...and Physical Examination to Assess for PAD...
...In patients at increased risk of...
...patients at increased risk of PAD (Ta...
...Patients at Increased Risk for PADH...
...ble 6. History and Physical Examination Fi...
...le 7. Alternative Diagnosis for Leg Pain or Clau...
...2. Algorithm for Diagnostic Testing for...
...1. Resting ABI and Additional Physiological Testin...
...esting A...
...n patients with history or physical examinati...
...e resting ABI should be reported a...
...ients at increased risk of PAD (Tab...
...patients not at increased risk of PAD...
...se ABI and Additional Physiological Testing...
...ts with suspected PAD, toe pressure/toe-brachial...
...s with suspected chronic symptomatic PAD (ie, exe...
...with PAD and an abnormal resting ABI...
...n patients with chronic symptomatic PA...
...with suspected CLTI, it is reasona...
...patients with CLTI with nonhealing wounds or...
...tive Diagnoses for Nonhealing Lower Ext...
...maging for PAD...
...tients with functionally limiting c...
...ents with CLTI, duplex ultrasound, CTA, MRA, or c...
...patients with suspected PAD (ie, potential signs...
...with a confirmed diagnosis of PAD in whom revas...
...iderations in PAD: Risk Amplifiers, Health Dispari...
...plifiers of Cardiovascular and Limb-Relate...
...luation of patients with PAD, clinici...
...D-Related Risk AmplifiersHaving trouble view...
...th Disparities and PAD-Related Risk A...
4.2. Health Disparities...
...linicians and health care systems should actively...
...derations in Management of PAD in O...
...lder patients (ie, ≥75 years of age) with...
...e 10. Geriatric Syndromes and Cons...
Treatment
...eatment
...l Therapy and Preventive Footcare for Pati...
...edical Therapy and Foot Care for PAD...
...Antiplatelet and Antithrombotic Therapy f...
...atients with symptomatic PAD, singl...
...patients with symptomatic PAD, single...
...In patients with symptomatic PAD, single a...
...with symptomatic PAD, low-dose rivaroxaban...
...vascular or surgical revascularization for PAD, an...
...After endovascular or surgical revascularization...
...endovascular revascularization for PAD, dual ant...
...After endovascular or surgical revasc...
...tients with asymptomatic PAD single antiplate...
...nts with symptomatic PAD without recent...
...ts with symptomatic PAD, the benefit of vor...
...After surgical revascularization fo...
...with PAD without another indication (eg...
5.2. Lipid-Lowering Therap...
...with PAD, treatment with high-intens...
...In patients with PAD who are on maximally tole...
...with PAD who are on maximally tolerated statin...
...able 11. High-, Moderate-, and Low-...
....3. Antihypertensive Therapy...
...s with PAD and hypertension, antihypertens...
...ents with PAD and hypertension, a sys...
...ith PAD and hypertension, the selective use...
...ing Cessation for PAD...
...atients with PAD who smoke cigarettes or use any...
...with PAD who smoke cigarettes or u...
...with PAD should be advised to avoid exposure to...
...abetes Management for PAD...
...ith PAD and type 2 diabetes, use of glucago...
...atients with PAD, management of diabetes shoul...
...with PAD and diabetes, glycemic control may...
...er Medical Therapies for Cardiovascular Risk...
...with PAD should receive an annual influe...
...nts with PAD should receive the sever...
...at high cardiovascular risk, a diet emphasizing...
...patients with PAD, B-complex vitamin supplem...
...patients with PAD, chelation therapy (eg,...
...patients with PAD, vitamin D supplement...
....7. Medications for Leg Symptoms in Chronic...
...ostazol
...tients with claudication, cilostazol is r...
...tients with PAD, cilostazol may be u...
...In patients with PAD and congestive heart fai...
...toxifylline
...ith chronic symptomatic PAD, pentoxifylline is...
...lation Therapy
...s with chronic symptomatic PAD, chelation the...
...entive Foot Care for PAD
...ts with PAD, providing general preventive foot sel...
...with PAD, foot inspection by a clinician...
...s with PAD at high risk for ulcers...
...patients with PAD, a comprehensive foot ev...
...with PAD, referral to a foot care specialist, whe...
...e 12. Risk Factors for Development of Foot Ulce...
...omponents of a Comprehensive Foot...
...Exercise Therapy for PAD...
...patients with chronic symptomatic PAD, SET i...
...In patients with chronic symptomatic PA...
...ho have undergone revascularization for chronic sy...
...ts with functionally limiting claudication, SET o...
...s with chronic symptomatic PAD, alte...
...n patients with chronic symptomatic PAD, th...
...ith chronic symptomatic PAD, the use...
...tured Exercise Programs for PADHaving tro...
...1. Revascularization for Asymptomat...
...In patients with asymptomatic PAD, it is reas...
...ients with asymptomatic PAD, revascularization...
...lgorithm for Revascularization for...
...ascularization for Claudication...
...ascularization for Claudication: Initial Decisio...
...ents with functionally limiting claudication w...
...ients with functionally limiting claudication and...
...patients with claudication who have had an...
...tion for Claudication: Aortoiliac...
...In patients with functionally limiting clau...
...atients with functionally limiting clau...
...vascularization for Claudication: Common Femoral...
...ents with functionally limiting claudication...
...atients with functionally limiting claud...
...ion for Claudication: Infrapopliteal...
...n patients with functionally limiting claudica...
...ients with functionally limiting cla...
...uit for Surgical Revascularization for Femoro...
...patients who are undergoing surgical...
...re 6. Components of Care f...
...Algorithm for Management of CL...
....1. Team-Based Care for...
...ients with CLTI, a multispecialty care team shou...
...ble 15. Multispecialty Care Team for P...
...6. Factors That May Influence Revasculariz...
...evascularization for C...
...scularization Goals for CLT...
...atients with CLTI, surgical, endovascular, or hy...
...ents with CLTI, an evaluation for revascular...
...cularization Strategy for CLT...
...patients undergoing surgical revascu...
...In patients with CLTI due to infrainguinal di...
...In patients with CLTI who are candidates f...
...ts with CLTI for whom a surgical approach is sele...
...ients with CLTI and nonhealing wounds or g...
...with CLTI with ischemic rest pain (ie, wit...
...Minimizing Tissue Loss for CLTI...
...1. Pressure Offloading for CL...
...ients with CLTI and diabetic foot ul...
...h PAD and previous diabetic foot ulcers sh...
...Patients with CLTI and foot ulcers who d...
...2. Wound Care and Management of Infection for...
...In patients with CLTI, prompt ma...
...s with CLTI with nonhealing wounds,...
In patients with CLTI with nonhealing di...
...able 17. Components of Wound Care for Patients...
...0.3.3. Approach to the “No Option” P...
...ients with CLTI for whom revascularizati...
...patients with CLTI for whom revascularization is...
...patients with CLTI for whom arter...
...omic Classification of the "No Option" P...
10.3.4. Amputation fo...
...ts with CLTI who require amputation, evaluation...
...atients with CLTI, primary amputation is indicate...
...ts with CLTI, a patient-centered approa...
...ts with CLTI undergoing minor amputation (ie...
...ts with CLTI, retrospective assessment...
...Major Factors Influencing QOL Among Amputees...
...tient Factors
...Walking with prosthesis Above knee (versus bel...
...sional-Controlled Factors...
...of amputation Informed decision makin...
...cute Limb Ischemia...
...igure 8. Algorithm for Diagnosis and...
...1. Initial Clinical Evaluation and...
...h ALI should be evaluated on an emergency...
...In patients with suspected ALI, the initial clin...
...In patients with ALI who have a complicated...
.... Management of AL...
...Revascularization for...
...ith ALI and a salvageable limb, revascula...
In patients with ALI and a salv...
In patients presenting with ALI from c...
...s with ALI with a nonsalvageable limb, revasculari...
...2.2. Adjunctive Therapies to Minimize Tissue...
...Patients with ALI should be monitor...
...ith ALI with a threatened but salvageable li...
...In patients with ALI and prolonged ischemia...
...3. Anticoagulation for ALI...
...nts with ALI, regardless of cause or anatomic...
...ic Evaluation for the Cause of ALI...
...n patients with ALI, a comprehensive medic...
...with ALI, testing for a cardiovascular c...
...e 20. Underlying Causes of ALIHaving trouble vie...
...ngitudinal Follow-Up of...
...l Principles...
...with PAD, with or without revascularization, lon...
...ith PAD, coordination of care among clinicians t...
Functional Status an...
...tients with PAD, with or without revascula...
...ical Therapy...
...atients with PAD, long-term use of GDMT t...
Postrevascularization Follo...
...with PAD who have undergone lower extremity...
...In patients with PAD who have undergone lowe...
...ients with PAD who have undergone infrai...
...patients with PAD who have undergon...
...tients with PAD who have undergone infraingui...
Telehealt...
...ts with PAD, telehealth can be an alternative...